Hillside Assisted Living Community

Based on record review and staff interview, the facility failed to have a written transfer agreement with other facilities in the event they cannot meet the residents needs and they require transfer. This has the potential to affect all 24 of 24 residents in the facility. The facility census was 24.

Findings include:

Review of the facility's evacuation plan, dated 03/15/23, revealed a plan to safely evacuate residents using a priority order list based on available space. Six facilities were listed in the evacuation plan.

Interview with Administrator on 01/17/24 at 2:22 P.M. verified there was no written agreement for transfer with another facility. The Administrator stated the facility will have to call facilities during the transfer incident to see if they have available beds. The Administrator stated she was told the other facilities don't write contracts for written transfer agreements.

Based on review of a personnel file, staff interview, and review of staff schedules, the facility failed to ensure staff received proper training prior to providing personal care services to residents. This affected one (Medication Aide #12) out of six personnel files reviewed for training. This had the potential to affect all residents at the facility. The facility census was 19.

Finding include:

Review of the personnel file for Medication Aide (MA) #12, hired 02/2023, revealed MA #12's job responsibilities included to provide personal care services to residents. MA #12 did not have any certification or license related to healthcare. Review of the training check off for MA #12 revealed the Business Office Manager/Executive Director completed MA #12's check off list and orientation verifications. MA #12 did not have any training completed by or signed off by an Registered Nurse (RN) or Licensed Practical Nurse (LPN) with RN oversight.

Interview on 06/26/23 at 8:35 A.M. with Nurse Manager #9 revealed she was the only nurse on staff and worked four to five days per week, and was an Licensed Practical Nurse (LPN).

Interview on 06/26/23 at 9:27 A.M. with MA #12 revealed the facility completed minimal training and MA #12 had little understanding of his job responsibilities. MA #12 indicated he provided personal care without supervision.

Interview on 06/29/23 at 1:42 P.M. with Executive Director #27 revealed staff are trained to perform their job and this training is overseen by the nurse and signed off by the Registered Nurse (RN) that works with the facility Nurse Practitioner (Medical Providers Nurse #70).

Interview on 06/29/23 at 2:03 P.M. with Medical Providers Nurse #70 revealed she works with the Nurse Practitioner, but had not been to the facility and does not oversee staff training at the facility. She also reported she was an LPN not an RN.

Interview on 06/29/23 at 3:00 P.M. to 3:40 P.M. with Nurse Manager #9 and Executive Director (ED) #27 revealed the nurse manager was not onsite during all training's and confirmed she does not come in to facility to supervise any night staff training's. Nurse Manager #9 and the ED had no knowledge of the staff training regulations and revealed the facility only had a training policy related to being CPR (cardiopulmonary rescucitation) certified and having received first aide training.

Review of the schedule revealed MA #12 worked on 06/18/23, 06/21/23, and 06/22/23 night shifts. The night shifts were scheduled as 12 hour shifts from 6:00 P.M. to 6:00 A.M. and could include assisting with personal care services to residents as the night aides were the only staff working during their individual shifts.

This violation represents non-compliance investigated under Complaint Number OH00143905.

Based on medical record review, staff interview, and policy review, the facility failed to ensure residents were assessed timely after a fall. Additionally, the facility failed to contact resident sponsors after falls, changes in conditions, and transfers to the hospital. This affected two (Residents #17 and #19) of three residents reviewed for falls. The facility census was 19.

Findings include:

1. Review of the medical record for Resident #19 revealed an admission date of 06/26/18. Diagnoses included chronic paranoid schizophrenia and abnormal results of liver.

Review of Resident #19's facesheet, dated 06/26/18, revealed Resident #19's brother was listed as an emergency contact. There was a phone number listed in order to contact Resident #19's brother.

Review of the progress notes, dated 02/28/23, revealed Resident #19 was alert but forgetful.

Review of the progress note, dated 03/20/23, revealed a mini mental exam was initiated and Resident #19 was noted to be confused and unable to answer questions.

Review of the Fall Assessment, dated 04/27/22, revealed Resident #19 was at high risk for falls.

Review of the In House Report, dated 05/28/23 at approximately 7:00 P.M., revealed Resident #19 had fallen and hit his head.

Review of the progress note, dated 05/29/23, revealed Resident #19 reported to the medication room staff that the previous night (05/28/23) he fell on his right hip and hit his head. Resident #19 reported his hip hurt, but denied pain to his head. Resident #19 was assessed and found no bruising, lumps, or bumps. The facility had no documentation to support Resident #19's family was contacted after the fall was identified.

Review of the Incident Report, dated 05/29/23 at 7:30 A.M., revealed Resident #19 reported the next day at medication time that the previous evening he fell and hit his head. Resident #19 reported some hip pain but no head pain. The aide checked Resident #19's hip and head with no bruising or bumps identified. The incident form revealed no documentation of Resident #19's family/emergency contact having been notified.

Review of an undated incident report revealed a fall involving Resident #19 had been reported to the day aide on 06/18/23 by the night aide. The incident report further revealed Resident #19 had a fall in the hallway when leaving the bathroom. It was reported that Resident #15 found Resident #19 and informed staff of the fall. The aide working picked up Resident #19 and put him to bed. The report stated the aide working was unable to get into the medication room to write a report and was unable to check Resident #19's vitals after the fall. The report stated Resident #19's vitals were checked at 6:30 A.M. the next morning. The incident investigation did not have documentation of Resident #19's family/emergency contact having been notified of the incident.

Review of the progress note, dated 06/20/23, revealed the nurse manager was told when she came in for work that Resident #19 had fallen on 06/18/23 as he was leaving the bathroom. When she went to see the resident to assess him, he was slow to respond, with pupils equal and hand grasps equal, and he answered appropriately. Resident #19 was sent to the hospital for evaluation. The medical record revealed no evidence of Resident #19's family having been notified of the fall or the hospitalization. Additionally, there was no documentation to indicate Resident #19 refused for his emergency contact/family to be notified of the fall/hospitalization and/or requested they were not notified of the fall/hospitalization.

Interview on 06/26/23 at 8:35 A.M. with Nurse Manager #9 revealed she was the only nurse on staff and worked four to five days per week. She reported she gets called for medical needs that arise when she is not present in the facility.

Interview on 06/26/23 at 9:27 A.M. with Medication Aide (MA) #12 revealed MA #12 was working when Resident #19 fell. MA #12 reported MA #12 did not have a key to the medication room which contained the equipment to check Resident #19's vitals. MA #12 revealed Resident #12's vitals were not checked, Resident #12 did not have any visible injuries and was transferred into a wheelchair and then into bed. MA #12 also reported he tried to contact the nurse and supervisor but did not receive a response, and had not created an incident report due to the documents being locked in the medication room. MA #12 reported he did not contact Resident #19's family after the fall.

Interview on 06/26/23 at 12:19 P.M. with Nurse Manager #9 revealed Resident #19 was transferred to the hospital due to altered mental status. She revealed the fall was not the cause of Resident #19's hospitalization.

2. Review of the medical record for Resident #17 revealed an admission date of 09/26/22. Diagnoses included seizures, muscle weakness hypothyroidism, delusional disorder, and anxiety.

Review of Resident #17's facesheet, dated 09/26/22, revealed Resident #17's sister in law was listed as a family contact. There was a phone number listed in order to contact Resident #17's sister in law.

Review of the Annual Assessment, dated 10/04/22, revealed Resident #17 required assistance with housework, meals, legal affairs, transportation, managing finances and laundry.

Review of the progress notes, dated 05/30/23 at 6:10 A.M., revealed Resident #17 fell in the hallway. Resident #17 reported she felt dizzy and hit her head. Resident #17 was assessed and no lumps or bumps were noted and Resident #17 got up on her own. The progress note, dated 05/30/23, revealed staff went to Resident #17's room around 11:30 A.M. and found that the resident refused to go to lunch. Resident #17 informed staff she fell again in her room, but refused for an exam to be completed.

Review of the progress note, dated 06/12/23, revealed Resident #17 had fallen on 06/11/23 around 11:23 P.M. and had a laceration to her head. Resident #17 was sent to the hospital for evaluation. Around 9:30 A.M., Resident #17 returned with seven sutures without drainage and denied pain or discomfort.

Review of the progress note, dated 06/13/23, revealed Resident #17 had another fall and was found to have fallen on her bottom in her room.

There was no documentation to indicate Resident #17's emergency contact/family was contacted after Resident #17's falls on 05/30/23, 06/11/23, and 06/13/23. Additionally, there was no documentation to indicate Resident #17 refused for her emergency contact/family to be notified of the falls and/or requested they were not notified of the falls.

Interview on 06/26/23 at 9:48 A.M. with MA #25 revealed she was working when Resident #17 fell and cut her head open. MA #25 reported she tried to contact the nurse and was unable to reach her so she decided to send Resident #17 to the hospital for sutures.

Interview on 06/29/23 at 3:40 P.M. with Nurse Manager #9 revealed facility staff do not contact the resident's family or emergency contact after a change in condition or hospital transfer. She revealed the facility only contacted the power of attorney (POA) if a resident had one, otherwise they were their own decision maker. The Nurse Manager revealed no knowledge of the facilities change in condition policy.

Review of facility policy titled Change in Resident Status

Based on review of the menu, staff interview, and policy review, the facility failed to ensure the facility menu was based on a standard meal planning guide from a diet manual published by a dietitian or approved by a dietitian. This had the potential to affect all 19 residents who receive meals from the kitchen. The facility census was 19.

Findings include:

Review of the menu, dated 06/2023, revealed there were no serving sizes for any of the meals on the menu. Additionally, there was no evidence on the menu that it was created in order to meet the dietary referenced intake of the Food and Nutrition Board of the National Academy of Science or followed any meal planning guidance from a diet manual that was created, reviewed, or approved by a dietitian. The menu for 06/02/23 revealed mashed potatoes was served at lunch and was the only vegetable served on 06/02/23. Additionally, the only fruit served on 06/02/23 was banana at breakfast. The menu for 06/25/23 revealed the only vegetables served on 06/25/23 were potatoes and green beans. Additionally, the only fruit served on 06/25/23 was strawberries.

Interview on 06/26/23 at 7:25 A.M. with Kitchen Staff #5 revealed the facility did not have a dietary manager. Kitchen Staff #5 revealed she had only been working at the facility for a few weeks.

Interview on 06/28/23 at 9:21 A.M. with Executive Director #27 and Owner #11 revealed the facility does not use a dietitian when creating their menu. They reported the menu creation was a team effort and was completed by the management team. They confirmed they do not use any resources when creating the menu including meal planning guides or a dietitian to review and approve the menu. The Executive Director reported the veterans affairs staff completes annual inspections which include the kitchen and during their inspections, they review the menu posted at the time of their inspection and make recommendations such as a serving of fruit needs to be added to breakfast. Executive Director confirmed the veterans affairs last inspected the facility on 11/02/22.

Interview on 06/28/23 at 4:45 P.M. with Kitchen Staff #21 revealed the facility menu does not include serving sizes and staff do not get any guidance on what serving sizes to provide to the residents. Kitchen Staff #21 reported staff use previous expertise to know how much food to make and serve residents. Kitchen Staff #21 reported the menu used to be created and reviewed by a dietitian, but now the menu was created by management staff and the kitchen staff were not involved in the process.

Review of facility policy titled Meals, Diets and Snacks

Based on medical record review, observation, staff and resident interviews, review of cleaning logs, and policy review, the facility failed to maintain clean and sanitary environment. This affected one (Resident #10) of three residents reviewed for environment. The facility census was 19.

Findings include:

Review of the medical record for Resident #10 revealed an admission date of 04/03/18. Diagnoses included anemia, hypertension, and chronic kidney disease stage four.

Review of the Annual Assessment, dated 08/09/22, revealed Resident #10 required assistance with housework and laundry.

Observation on 06/26/23 from 7:30 A.M. through 5:00 P.M. revealed Resident #10's bed was near the wall and Resident #10's box spring had a cover on it that had large stains which were roughly the size of dinner plates and were located on the side of the box spring that faced into the room. Near the head side of the bed, there was a large brown stain and near the middle of the bed there was a large dark yellow stain. The stains were able to be seen from the hallway.

Observation on 06/27/23 at 9:50 A.M. to 6:00 P.M. revealed Resident #10's box spring still had two large stains. Housekeeping was observed in the facility on this date and was mopping the hallways. Housekeeping staff was not observed cleaning any resident rooms. Resident #10's door had a file shelf which included an information flier about bed bugs and a cleaning checklist dated April 2023. The last date cleaning was checked off was in April 2023.

Observation and interview on 06/28/23 at 12:40 P.M. with Resident #10 revealed facility staff wash his laundry including bed linens. He revealed he used to have his sheets changed weekly but could not recall the last time his bedding was replaced and confirmed the stain on his bed had been their awhile. Resident #10 also reported he would like his linens changed and revealed he did not want the stain on his bed. Resident #10 reported he was unable to physically change his linens on his own.

Interview on 06/28/23 at 3:40 P.M. with Medication Aide (MA) #36 confirmed no housekeeping staff were working at the time of the interview and confirmed Resident #10 had two large stains on his box spring linen and one was dark yellow in the middle of the bed and the other was a brown stain near the head of the bed. MA #36 revealed she thought the stains occurred over the weekend and was unable to explain why they had not been changed yet. MA #36 also confirmed residents had a cleaning checklist outside the door and confirmed Resident #10's cleaning checklist was dated 04/2023 and did not include any recent cleaning had been conducted.

Review of the Cleaning Logs revealed Resident #10 had daily cleaning checked off on 04/01/23 through 04/07/23 and weekly and monthly cleaning checked off on 04/01/23. No cleaning checkoffs were available or completed since 04/07/23.

Review of facility policy titled House Rules and Policies

Based on medical record review, staff interview, and policy review, the facility failed to ensure discharged resident records were maintained and stored for at least seven years. This affected two (Residents #23 and #25) of three discharged residents reviewed. The facility census was 19.

Findings include:

1. Review of the medical record for Resident #25 revealed an admission date of 05/04/21. Diagnoses included chronic obstructive pulmonary disease, depression, hyperlipidemia, and peripheral vascular disease. Resident #25 discharged from the facility however the medical record did not include an exact discharge date.

Review of Initial Assessment for Resident #25 revealed it was undated and only included page one of the assessment.

Review of Resident #25's medical record revealed no evidence of weights having been obtained and monitored for Resident #25 throughout his admission. Additionally, there were no progress notes available for Resident #25, no documentation related to discharge planning or services, no mental status exam, no inventory of items, no medication records, and no evidence of physician visits.

Multiple interviews between 06/28/23 at 4:00 P.M. and 06/29/23 at 3:40 P.M. with Nurse Manager #9 and Executive Director (ED) #27 revealed the facility was unable to find evidence of a complete medical record for Resident #25. The Nurse Manager revealed she brought out all that she could find. The Nurse Manager confirmed there were no weights available for Resident #25, there were no progress notes available, no records from discharge planning or services, no mental status exams, no inventory of items, no medication records, and no evidence of physician visits.

2. Review of the medical record for Resident #23 revealed an admission date of 03/28/23. Diagnoses included parkinsonism due to treatment for schizoaffective disorder, kidney disease stage three, heart failure, and generalized weakness. Resident #23 discharged from the facility however the medical record did not include an exact discharge date.

Review of Resident #23's medical record revealed no evidence of a service plan and inventory sheet.

Review of Resident #23's medical record revealed no evidence of progress notes having been completed, documentation from discharge planning or services, or physician orders.

Multiple interviews between 06/28/23 at 4:00 P.M. and 06/29/23 at 3:40 P.M. with Nurse Manager #9 and ED #27 revealed they were unable to find evidence of a complete medical record for Resident #23.

Review of the facility policy titled Resident Records Storage Guidelines